Cerebral vascular problems are diagnosed by computed tomography (CT) or magnetic resonance imaging (MRI) and cerebral angiography-Digital subtraction angiography (DSA).
Angiography is done to image the arteries and veins in the brain and look for vascular problem. A contrast dye is injected into the brain's vasculature by a catheter that is inserted through the groin or forearm and travels through the arteries into the neck. After that, an x-ray picture is obtained to show the blood arteries and check for anomalies like aneurysms.
Endovascular Management
Endovascular refers to inside or endo the blood vessels. Therefore, endovascular procedures are minimally invasive methods that use wires and thin, flexible tubes (catheters) that are placed into blood vessels. The incision site is much smaller than with open surgery. In order to reach the location of the vascular issue in the brain, catheters might be placed into a blood vessel in the arm or groin. Once the desired location is reached, embolic agents are delivered to treat Aneurysm, fistula and AVMs respectively.
Aneurysm
Options for aneurysm treatment vary depending on the patient’s age, condition and size, type and location of aneurysm. Treatment is necessary for aneurysms greater than 7 mm (even if they have not ruptured) and those that burst and cause bleeding, regardless of size. Smaller aneurysms can be tracked over time, particularly if they are discovered by accident and don't cause any symptoms.
Endovascular Procedure
By passing a catheter through the arteries from the groin or forearm to the brain, endovascular treatments eliminate the need to penetrate the skull directly.
Using a cathlab, an interventional neuroradiologist will insert the catheter into the artery that is impacted and insert platinum coils into the aneurysm, either with the use of a stent or a balloon. The aneurysm is blocked by the coils. A blood clot eventually develops to successfully close off the aneurysm.
FLOW DIVERTER
The effectiveness of cerebral aneurysms treated with coil embolization with or without a combination of stent or balloon assistance depends on neck size and dome-to-neck ratio. The recent development of flow-diverting (low porosity) stents has added another option to the endovascular armamentarium. Cerebral aneurysm characteristics are better obtained from cerebral digital subtracted imaging and 3D rotational angiography.Flow diversion is a treatment technique used for large or giant wide-necked intracranial aneurysms, fusiform aneurysm, Multi segmental aneurysms, Small dissecting blister aneurysms and Aneurysm with an important vessel coming from this sac.
By placing a flow diverter in the parent vessel blood flow is redirected away from entering the aneurysm. The blood within the aneurysm then stagnates and undergoes thrombosis. Over time, a new endothelium develops across the neck, thereby reconstructing the parent vessel and curing the aneurysm yet providing blood flow through adjacent side branches.
DAVFs
A DAVF occurs when an improper contact between an artery and a vein, such as a fistula, occurs close to the dura, the outer layer of the brain. The shunt of blood from the carotid artery to the cavernous veins is known as a carotid cavernous fistula (CCF).
Embolization
The main treatment for DAVFs is embolization. Embolization begins with the same process as diagnostic angiography, which involves inserting a catheter into a groin artery and guiding it to the DAVF's blood arteries. An occluding liquid substance (N-butyl cyanoacrylate (NBCA)/ethylene-vinyl alcohol copolymer) is administered to the DAVF's blood arteries in place of a contrast dye injection in order to stop aberrant blood flow.
Arteriovenous malformations (AVMs)
Brain tangles of aberrant arteries and veins without tiny blood vessels called capillaries connecting them are known as arteriovenous malformations (AVMs). Blood flow becomes erratic as a result, which may ultimately lead to vascular rupture and bleeding.
The size, location and nature of the AVM and surrounding blood arteries determine the course of treatment. Interventional neuroradiologists can use embolization to treat small lesions; in order to make surgery safer, other lesions may need the aberrant arteries supplying the AVM to be embolized (blocked) before surgery.
Stroke
During a stroke, things move quickly once you get to the hospital. Emergency team works to learn what type of stroke you're having by CT scan and MRI. In ischemic stroke, blood vessels in the brain are blocked. Hemorrhagic stroke, there's bleeding into the brain.
Ischemic stroke, blood flow must quickly be restored to the brain by IV Medicine.
Endovascular procedure - Mechanical thrombectomy is especially helpful for people with large clots with less than six hours from the start of symptoms. Interventional Neuroradiologist in this procedure uses the same initial procedure as diagnostic angiography, which a catheter is passed through an artery from groin and then guided to the blood vessels of occlusion and the clot is removed with a special grasping device - stent retriever or suction device. Device can directly remove the clot from the blocked blood vessel in the brain. Endovascular therapy must be performed as soon as possible to improve outcomes and reduce long-term disability after ischemic stroke.
The time window for this procedure can be expanded upto 24 hours (Golden day) by using advanced imaging technology of CT or MRI Perfusion and selecting ideal candidate benefitting from endovascular therapy.
Carotid stenting
Significant carotid stenosis Can cause stroke or Stroke-like symptoms. The risk of a stroke recurring is about 25 percent in two years without treatment. Carotid artery disease can be detected Ultrasound Doppler Scan, CT Angiogram or MRI Angiogram. Carotid stenting may be appropriate stroke treatments or stroke-prevention options if a carotid artery with a blockage of 70% or more and especially in patient with a stroke or stroke symptoms.
Interventional Neuroradiologist takes a catheter to the carotid arteries through an artery in the groin under local anaesthesia. Then a stent can be inserted to expand and support the opened artery.
Preoperative Embolization of Brain and Spine Tumors
Preoperative embolization can cut off the main blood supply to some big, highly vascular tumors of the brain, spine and head and neck, making surgical resection less risky and easier by minimizing blood loss. Preoperative embolization is frequently carried out in the days leading up to surgery and is provided as an adjuvant before open surgery. A catheter is inserted via the groin into the blood arteries supplying the tumor during embolization, which is done in a cathlab. To lessen blood flow to the tumor, selective angiography of the blood arteries is performed and then embolic material is injected into these feeding blood vessels.
Cerebral venous thrombosis (CVT)
In this condition blood clot forms in the brain venous sinuses and prevents blood draining out of the brain. Systemic anticoagulation with heparin (unfractioned or with low molecular weight) is the standard medical therapy, even in patients with hemorrhagic lesions. Endovascular treatment is indicated as rescue therapy in severe and refractory cases for medical treatment. Mechanical thrombectomy- Aspiration alone (suction thrombectomy) and a combined technique with a stentriever can be used to obtain adequate recanalization of the occlude sinus.
Idiopathic intracranial hypertension (IIH)
IIH patients frequently have unilateral or bilateral transverse sinus (TS) stenosis. Patients with medically refractory IIH have effective alternative of sinus stenting with pressure gradient (>8 mmHg). For patients with a stenotic TS, stent implantation may be a long-lasting and safe way to relieve symptoms, including as headaches and vision loss.
Inferior Petrosal Sinus Sampling (IPSS)
IPSS can identify a pituitary source in Cushing's syndrome patients by comparing the amounts of ACTH in peripheral blood samples and the petrosal sinus. By comparing the ACTH levels in the two petrosal sinuses, this test can also assist in lateralizing the location of a pituitary tumor.
Spinal vascular malformations
Spinal vascular malformations are the result of an abnormal connection between arteries and veins that occurs within the spinal canal or spinal dural covering. Spinal vascular problems are diagnosed by Spinal magnetic resonance imaging (MRI) and Spinal angiography. Majority of cases are treated by surgery or embolization based on type of malformation after careful individual consideration.
